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The Department of Veterans Affairs (VA) has come under scrunity by Congress, Veteran Service Organizations, media and in the veterans’ community for its failures in leadership performance and accountability which have resulted in quality of care or patient safety issues that have affected veterans. The following list outlines specific VA issues nationally as well as at Local VA Medical Centers and Regional Offices.

Nationally

VA fails to release internal documents that corroborated at least 19 preventable deaths and VA officials did not respond to direct questions in a House Veterans Oversight and Investigations Hearing on April 2, 2014.

Florida Governor Scott has convened a state inspection team to examine VA facilities in the wake of quality and patient safety issues.

At the conclusion of the Congressional Oversight and Investigation Hearing regarding “Correcting ‘Kerfuffles’ – Analyzing Preventable Patient Deaths at Jackson VAMC” on November 13, 2013, Chairman Coffman requested a report on how the G.V. (Sonny) VAMC is specifically addressing the concerns of understaffing, overbooked patients, lack of oversight for the medical center’s nurse practitioners, lack of patients’ access to physicians, and radiology reports being misread and unread within 30 days. On November 14, 2013, The American Legion requested a copy of the report and as of March 31, 2014, the VA has yet to provide the report. During our System Worth Saving Task Force site visit in Jackson MS on January 20-22, facility director Joe Battle was unable to give The American Legion a copy of the action plan the facility has taken to address the preventable deaths. Director Battle stated that he could release the report because it was not cleared by VA Central Office. Upon further requests for this information after our site visit, Veterans Health Administration staff told us that they could not release the report because Office of Congressional Legislative Affairs (OCLA) had not cleared or sent this response to Congress. Not only is Congress waiting for this information but the delays in OCLA responding to Congress have now spilled over and is affecting the abilities of The American Legion to effectively conduct our site visits and inform veterans in the communities of these hospitals. In anonymous conversations with VA Central Office staff, OCLA was first sent the action plan from VHA on December 6 has not approved or sent the response to Congress. Furthermore, OCLA just came back to VHA on March 26 to have VHA make adjustments/updates due to the time lag and the information being outdated.

Congress, Veteran Service Organizations and veterans that are being treated at medical centers with issues and concerns are frustrated, confused and out of the loop on the steps VA has taken to resolve problems which has led to a diminished confidence and renewed interest and pressing for more accountability on management of these facilities. Veterans in these communities continuously read newspaper articles which are not accurately portraying the action plan and steps VA is taking to correct issues because of the lack of communication and timeliness of VA offices in Washington DC to work together across VA Central Office and in responding to congressional inquiries.

The American Legion urges VA leadership from the Secretary’s office, Office and Public and Intergovernmental Affairs, the Office of Congressional Legislative Affairs and leadership/communication staff from VHA, VBA and NCA to ALL work together to develop a crisis communication team to expedite issues of critical nature as well as better coordination and response for general inquiries to best serve VA local sites leadership in responding to media, veteran service organizations and veterans.

A December 2012 audit of the Fayetteville VA Medical Center found facility employees did not complete required suicide prevention follow-ups 90 percent of the time for patients at a high risk of suicide. The audit also found the center “noncompliant” in cleanliness of patient care areas, environmental safety, dental clinic safety, training and testing procedures. In July 2012, during an investigation that substantiated patient misdiagnosis complaints, VA’s inspector general found the responsible physician failed to properly review medication information 56 percent of the time, a step that is “critical to appropriate evaluation, treatment planning, and safety.” Fayetteville VA Medical Center Director Elizabeth B. Goolsby received a performance bonus of $7,604 in 2012.

In September 2013, six deaths were linked to delayed screenings for colorectal cancer at the veterans medical center in Columbia, S.C., the Veterans Affairs Department reported. The VA’s inspector general determined that the William Jennings Bryan Dorn VA Medical Center fell behind with its screenings because critical nursing positions went unfilled for months. It also found that only about $275,000 of $1 million provided to the hospital to alleviate the backlog had been used over the course of a year.

Waco, Texas

Carl Lowe, the former director of the VA regional office in Waco, Texas, raked in more than $53,000 in bonuses as the office’s average disability claims processing time grew to historic levels, forcing veterans to wait longer than anywhere else in the country.

Ray Velez, an active Legionnaire from American Legion Post 61 in Junction City, went to the Roseburg VA Medical Center this past June for what should have been a routine hernia operation. After the surgery, Roseburg VA Medical Center staff told Irene Lillie, Velez’s daughter, that her father’s blood pressure had “dropped suddenly and he was having difficulty breathing.” Since the Roseburg VA Medical Center does not have an Intensive Care Unit, Velez was taken to PeaceHealth Sacred Heart Medical Center at Riverbend in Springfield, Oregon. Unfortunately, Velez passed away en route PeaceHealth Sacred Heart Medical Center due to “intra-dominal bleeding, shock, hyperkalemia, acidosis, respiratory failure and recent ventral hernia surgery.”

Butler, Pennsylvania (Site Visit Jan. 8-9, 2014)

An attorney for the prime contractor of a Department of Veterans Affairs outpatient center being built in Butler County declined to comment Friday, July 12, 2013 about the VA's investigation of the contractor that led the agency to stop work on the $75 million project.

The VA Butler Healthcare Center was scheduled to open in 2015, but the termination of the lease left its future in doubt. The VA broke ground on the center in April 2013. The Department of Veterans Affairs yanked its lease with an Ohio company that was building a $75 million health center for vets in Butler, accusing the firm of “false and misleading representations” during bidding. The VA ordered work halted in June when it began to uncover problems with the project.

The Department of Veterans Affairs failed to properly check the qualifications of the former developer of an outpatient center in Butler County, according to a highly critical report by the VA's Office of Inspector General released Monday. The report says the VA improperly calculated that a 20-year lease with Westar Development Co., valued at $157 million, would be cheaper than the VA building and owning the $75 million outpatient center on its own.

Costs substantially increased and schedules were delayed for Department of Veterans Affairs' (VA) largest medical-center construction projects in Denver, Colorado; Las Vegas, Nevada; New Orleans, Louisiana; and Orlando, Florida. As of November 2012, the cost increases for these projects ranged from 59 percent to 144 percent, with a total cost increase of nearly $1.5 billion and an average increase of approximately $366 million. The delays for these projects range from 14 to 74 months, resulting in an average delay of 35 months per project. In commenting on a draft of this report, VA contends that using the initial completion date from the construction contract would be more accurate than using the initial completion date provided to Congress; however, using this date would not account for how VA managed these projects prior to the award of the construction contract. Several factors, including changes to veterans' health care needs and site-acquisition issues contributed to increased costs and schedule delays at these sites.

Jackson, Mississippi (Site Visit Jan.21-22, 2014)

At the G. V. Sonny Montgomery VA Medical Center in Jackson, MS, multiple whistleblower complaints have been raised by employees who were losing confidence in the medical center’s ability to treat veterans. The complaints ranged from improper sterilization of instruments to missed diagnoses of fatal illnesses, as well as hospital management policies.

Augusta, Georgia (Site Visit Mar. 11-12, 2014)

CNVAMC leadership first learned of delays in providing gastrointestinal (GI) services to veterans on August 30, 2012. Of the 4,580 delayed GI consults, a quality management review team determined 81 cases for physician case review. Seven of the 81 cases may have been adversely affected by delays in care. Six of seven institutional disclosures were completed and three cancer-related deaths may have been affected by delays in diagnosis. Factors contributing to the 4,580 patient backlogs included an explosion of baby boomers turning 50 and requiring screening, the medical center’s non-anticipation of a spike in GI consult demand, lack of an integrated data base for tracking GI procedures, and GI physician recruitment challenges.

On Tuesday, April 1, 2014, it was revealed that Veterans Affairs Department financial manager Jed Fillingim was involved in a deadly incident while traveling on business for the agency in 2010. Police and federal investigators found Fillingim drove a government truck after drinking with two colleagues at a bar near Dallas while attending a June 2010 conference for federal employees. One of the two colleagues, Mississippi-based VA employee Amy Wheat, who had also been drinking that night, fell out of the truck while it was moving and died. She suffered severe head injuries and a severed leg in the fall. Blood covered the truck and one of its wheel wells, according to police reports.

Though he resigned from his position with the agency’s Jackson, Miss., medical center five months later, the News4 I-Team has learned Fillingim was rehired in March 2011 and has since assumed a high-level managerial position in Augusta, Ga., earning more than $100,000 per year.

Memphis, Tennessee

In October of 2013, The VA Office of Inspector General Office (VA OIG) of Healthcare Inspections conducted an inspection in response to an allegation of inadequate care for patients who died in the Emergency Department (ED) at the Memphis VA Medical Center (the facility), Memphis, TN. The complainant alleged that a patient died after a physician ordered a medication for which the patient had a known drug allergy; another patient died after being administered multiple sedating drugs and not being monitored properly; and a third patient died after delays in getting treatment for very high blood pressure.

Des Moines, Iowa

The VA Office of Inspector General Office of Healthcare Inspections conducted an inspection in response to a request by Senators Charles Grassley and Tom Harkin, both of whom received allegations of ongoing administrative irregularities, leadership lapses, and quality of care concerns over the past 2 years at the VA Central Iowa Health Care System.

San Francisco, California

In a VA Inspector General report on the San Francisco VA hospital and clinic, the agency's inspector general reviewed 264 opiate prescription renewals and found that in 53 percent of cases, the doctor renewing the prescription had not seen the patient or talked to him or her over the telephone.

More in Veterans Health Center

Brett T Lauderdale

I want to add here that there are some VA facilities in which there are caring, dedicated staff. I have been going to the Iron Mountain. MI VA Hospital for over 10 years and i'ts not perfect, but it's darn close. I am lucky to have them there for me as they have saved my life. I have always received high quality care and respect from those who have been charged with caring for me. Jus' sayin'.

cowboyup

ATTENTION ALL VETERANS : Very important information. I'm not advising just sharing.
Federal T.O.R.T. Law. Under these serious and twisted Veterans Administrative abusive and neglected behaviors, you may want to look at this law. I could be very useful because in most cases no one will share this with you when it comes to a corrupt medical malpractice and premeditated disgusting way's of murdering our Brothers and Sister Veterans.

cowboyup

TUCSON VA HOSPITAL NEEDS TO BE INVESTIGATED AS WELL AS PHOENIX REGIONAL RATINGS OFFICE ON APPOINTMENT DELAYS AND FALSE INFORMATION DISCUSSED WITH VETERANS FROM BOTH SIDES.
After requesting to see my Doctor last month and told my next appointment was in September 2014. I was pissed and hung up. My wife/caregiver was so upset she serached outside resourses. I now have an appointment for a Cancer Screening Ive been needing from the VA for Two years now. My last visit I had at the Ironwood Clinic last year, I was told the bigger the growth the better. As a Veteran you want to be able to trust what a VA Doctor tells you. But now, I'm stuck getting outside care and I pray when I get this screening its going to be negative. I'm only 55, I don't want to die right now. It I died during war then it was in honor of my country. If I die because the VA neglected to do their "Quality of Care". Then, how shameful it would be, when I could had been saved.

Joan E Clayton

My husband died in Bay Pines VAMC Bay Pines, FL. 12/23/12. The ROI, patient advocate, legal Counsel and District VA have "classified" his medical records due to delayed care, missing incident reports (3) and gross mismanagement for the last 18 months. I went through their chain of command and have now filed a FOIA with no reply, Criminal charges should be charged over the CYA cover your ass from the top down! What they have put us through before his death and myself since are in my opinion worse than the terrorist treatment. No veteran or his/her survivors should be treated like something stuck on the bottom of your shoe. Freedom is not free! Our veteran's service to this beloved country should not be treated like a cancer, PLEASE PRESS ON until this corrupt, criminal giant is taken down. Our Vets and our country earned this, God bless America and God help us in this matter, no more cover ups. It's time to take action.

AmIHomeYet

With regards to the big "Union" the VA Executives belong to - SES.
One does not need to look back to far in history to recall what President Regan did with the Air Traffic Controllers Union. He fired them all and the union was busted.
The White House would have us believe that President Obama is "madder than hell" over the VA criminal conduct (he hasn't nor have any of the politicians on either side of the Aisle equated these people to be criminally complicit to criminal negligent homicide and one could add defrauding the government to gain bonuses and running a criminal enterprise involved in Racketeering).
Is President Obama going to utilize his "Pen" as he has done to bypass Congress on other issues important to him to bust up the VA Union, whom I assume are his campaign supporters?
Doubtful!
So how mad are you Mr. President?
As a Veteran I am madder than hell! What say my fellow Veterans?

rodney_ward08

Congress needs to conduct criminal investigations on all the upper VA employees that were involved in any of the above criminal acts listed in the reports. Bonus should go to all Veterans that use any VA Medical Facilities. We as Veterans deserve better medical treatment. I also suggest that Congress close these VA Medical Centers and seek private medical care at the government expense for Veterans. ENOUGH IS ENOUGH.

curtis gaylord

I have a claim that has been pending since 1996,now my allegation(s)are retaliation for filing a complaint with the Director,discrimination because of race black,discrimination against the americans with disabilities act,5 complaints/ grievances written to the Director at Edward J. Hines JR. VA Hospital still not addressed,VA Medical Facilities should be held more accountable

US Retired

Now if any of us drove drunk and killed someone we would be in prison. I think having the OIG investigate is like having a brother tell on his brother to the law. I think we need someone else to investigate who has nothing to gain and will punish from the bottom to the top. Eric Shinseki needs to be fired and all his upper brass. I feel that nobody should get a bonus from here on. No more incentive to kill people.

Peter Floyd

If the American people really want change to occur in the VA system, then we should be asking the President to get rid of those in the SES (Senior Exicutive Service) that are the top managers and directors of these hospitals. Calling for Gen.Senkisi's ouster won't change a thing because he is in a politically/presidentially appointed position.It's the ones that sign FASCHE after their names that should be held accountable. Once they start loosing their jobs, then things will finally change in this behemoth of a system that we call the VA.

AmIHomeYet

General Shinseki should be speaking out loudly and clearly on a the extremely relevant issue that you bring up. Neither he nor Congress have stepped up and decided to take action against what I see as a corrupt and self serving group - the SES / FASCHE. The buck is going to have to stop somewhere. Given the number of Veterans currently in the system and those that are not Veterans should be demanding action from Congress. They should have the political will and power to tackle the problem and set things straight once and for all. Again: Veterans continue to suffer the costs of a broken bureaucracy!

AmIHomeYet

There are names listed in the above article that have been awarded and promoted yet still continue to conduct themselves as if they are above reproach and untouchable by Congress, the American Legion, other Veterans Organizations and Veterans. All under the watch of the Honorable Eric K. Shinseki. General Shinseki has received support from President Obama and we must consider all issues facing the Obama Administration that are evidence of continued deceit to the American People! Honorable Eric K. Shinseki needs to resign or be fired given the gravity of the evidence and allegations of miss-management by Veterans Administration officials under his control and responsibility. In many instances the conduct of Veterans Administration Administrators is intolerable and possibly criminal. Yet Honorable Eric K. Shinseki fails to take decisive action to address the glaring failures within the Veterans Administration. The VA continues to snub the requests and demands of the House Committee for Veterans Affairs.
Ultimately, by who and when are the people highlighted above going to be held accountable for their gross misconduct?
The time has come for an overhaul of a system rife with politics and abuse! The Veteran continues to suffer the costs!

Tim French

There should be a warning at the beginning of this article: MEDICAL ALERT - Reading this article could make your blood boil.
I would like to see an additional sentence at the end of each article where greed, malfeasance or over-payment for under-performance by the facility's director is addressed. In that sentence the name of the supervisor of that director during the time frame of the event should be given; where he or she is now; were they a recipient of a bonus; and if they are in a new position today, was that position a promotion.
I think there is plenty of room at the fire for senior feet as well as the multiple pairs of local feet.

DaMadOne

After all these years I am glad someone is making an attempt to do something. As far as the Baltimore VA medical center I still don't know if the orthopedics department ever got their act together. I gave up on relying on that department for care back in 09. My first referral to that department was in Jan 08 was marked urgent by my primary care and I began attempting to get an initial appointment which finally took place almost 4 months later after I had to meet with the hospital commander. I have also utilized the ER at odd hours and found their treatment very good. Also for several years there was a major construction project that took at least 5 years to complete. It sure looks pretty and I am not sure if any one in administration got bonuses. All I can say is if anyone did perhaps the money would have been better invested in a decent orthopedic surgical staff or an ambulance and driver to get us patients to their er.